Surprise Billing Compliance Checklist Form
Confirm completion of all required steps for surprise billing compliance. Use this checklist to verify and document each compliance action for your facility or department.
Facility or Department Identification
*
Facility/Department name is clearly identified
Address/location verified
Review Date and Responsible Staff Role
*
Review date recorded
Responsible staff role documented
Service Encounter Details
*
Service type and date/time confirmed
Attending provider(s) identified
Verification of Notice and Consent Materials
*
Required notice provided to patient
Consent materials reviewed and acknowledged
Network Status Check
*
In-network status confirmed
Out-of-network status documented
Out-of-Network Disclosure Review
*
Out-of-network disclosure reviewed with patient
Estimated costs explained to patient
Patient Communication Documentation
*
All communications with patient documented
Patient questions and responses recorded
Dispute or Escalation Handling
*
Disputes/escalations logged and addressed
Resolution steps documented
Final Compliance Status and Notes
*
All checklist items reviewed and completed
Additional notes documented
Submit Checklist
Should be Empty: